virginia tech shootings review panel report - 16 chapter ix

8/14/2019 Virginia Tech Shootings Review Panel Report - 16 CHAPTER IX

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CHAPTER IX. EMS RESPONSE

101

Chapter IX

EMERGENCY MEDICAL SERVICES RESPONSE

he tragic scenes that occurred at Virginia

Tech are the worst that most emergency

medical service (EMS) providers will ever see.

Images of so many students and faculty mur-

dered or seriously injured in such a violent man-

ner and the subsequent rescue efforts can only be

described by those who were there. This chapter

discusses the emergency medical response on

April 16 to victims including their pre-hospital

treatment, transport, and care in hospitals.

Interviews were conducted with first responders,emergency managers, and hospital personnel

(physicians, nurses, and administrators) to

determine:

The on-scene EMS response.

Implementation of hospital multi-

casualty plans and incident command

systems.

Pre-hospital and in-hospital initial

patient stabilization.

Compliance with the National Incident

Management System (NIMS).

Communications systems used.

Coordination of the emergency medical

care with police and EMS providers.

Evaluating patient care subsequent to the initial

pre-hospital and hospital interventions was

beyond the scope of this investigation. Fire

department personnel were not interviewed

because there were no reports of their involve-

ment in patient care activities

Although there is always opportunity for

improvement, the overall EMS response was

excellent and the lives of many were saved. The

challenges of systematic response, scene and

provider safety, and on-scene and hospital

patient care were effectively met. Responders are

to be commended. The results in terms of patient

care are a testimony to their medical education

and training for mass casualty events, dedica-tion, and ability to perform at a high level in the

face of the disaster that struck so many people.

The Virginia Tech Rescue Squad and Blacksburg

Volunteer Rescue Squad were the primary agen-

cies responsible for incident command, triage,

treatment, and transportation. Many other

regional agencies responded and functioned

under the Incident Command System (ICS). The

Blacksburg Volunteer Rescue Squad (BVRS) per-

sonnel and equipment response was timely and

strong. Virginia Tech Rescue Squad (VTRS), thelead EMS agency in this incident, is located on

the Virginia Tech campus and is the oldest colle-

giate rescue squad of its kind nationwide. It is a

volunteer, student-run organization with 38

members.1

Their actions on April 16 were heroic

and demonstrated courage and fortitude.

WEST AMBLER JOHNSTON INITIALRESPONSE

he first EMS response was to the West

Ambler Johnston (WAJ) residence hall inci-dent. At 7:21 a.m., VTRS was dispatched to 4040

WAJ for the report of a patient who had fallen

from a loft. In 3 minutes, at 7:24 a.m., VT Rescue

3 was en route. While en route, dispatch advised

that a resident assistant reported a victim lying

against a dormitory room door and that bloody

footprints and a pool of blood were seen on the

floor. VT Rescue 3 arrived on scene at 7:26 a.m.,

5 minutes from the time of dispatch. This

response time falls within the nationally ac-

cepted range.2

1VTRS. (2007).April 16, 2007: EMS Response. Presentation

to the Virginia Tech Review Panel. May 21, 2007, The Inn atVirginia Tech.2

NFPA (2004). NFPA 1710: Standard for the Organizationand Deployment of Fire Suppression Operations, EmergencyMedical Operations, and Special Operations to the Public byCareer Fire Departments. National Fire Protection Associa-tion: Battery March Park, MA.

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At 7:29 a.m., Rescue 3 accessed the dorm room to

find two victims with gunshot wounds, both

obviously in critical condition. At 7:31 a.m., it

requested a second advanced life support (ALS)

unit and ordered activation of the all-call tonerequesting all available Virginia Tech rescue per-

sonnel to respond to the scene. The all-call

request is a normal procedure for VTRS to

respond to an incident with multiple patients.

Personnel from BVRS responded to WAJ as well.

At 7:48 a.m., VT Rescue 3 requested that

Carilion Life-Guard helicopter be dispatched and

was informed that its estimated time of arrival

was 40 minutes. It was decided to dispatch the

helicopter to Montgomery Regional Hospital

(MRH). Carilion Life-Guard then advised that

they were grounded due to weather and never

began the mission.

One of the victims in 4040 WAJ was a 22-year-

old male with a gunshot wound to the head. He

was in cardiopulmonary arrest. CPR was initi-

ated, and he was immobilized using an extrica-

tion collar and a long spine board. VT Rescue 3

transported him to MRH. During communica-

tions with the MRH online physician, CPR was

ordered to be discontinued. He arrived at the

hospital DOA.3

The second victim was an 18-year-old female

with a gunshot wound to the head. She was

treated with high-flow oxygen via mask, two IVs

were established, and cardiac monitoring was

initiated. She was immobilized with an extrica-

tion collar and placed on a long spine board. At

7:44 a.m., she was transported by VT Rescue 2 to

MRH. During transport, her level of conscious-

ness began to deteriorate and her radial pulse

was no longer palpable.4

Upon arrival at MRH,

endotracheal intubation was performed. At 8:30

a.m., she was transferred by ground ALS unit to

Carilion Roanoke Memorial Hospital (CRMH), a

Level I trauma center in Roanoke, Virginia.5

3EMS Patient Care Report Q0669603.


5Turner, K. N., and Davis, J. (2007).Public Safety Timeline

for April 16, 2007. Unpublished Report. Montgomery CountyDepartment of Emergency Services, p. 4.

Following CPR that occurred en route she was

pronounced dead at CRMH.6

Based on the facts known, the triage, treatment,

and transportation of both WAJ victims

appeared appropriate. The availability of heli-

copter transport likely would not have affected

patient outcomes. Their injuries were incompati-

ble with survival.

NORRIS HALL INITIAL RESPONSE

t 9:02 a.m., VT Rescue 3 returned to service

following the WAJ incident. VT Rescue 2

continued equipment cleanup at MRH when the

call for the Norris Hall shootings came in. At

approximately 9:42 a.m., VTRS personnel at

their station overheard a call on the police radioadvising of an active shooter at Norris Hall.

Many EMS providers were about to respond to

the worst mass shooting event on a United

States college campus.

Upon hearing the police dispatch of a shooting at

Norris Hall, the VTRS officer serving as EMS

commander immediately activated the VTRS

Incident Action Plan and established an incident

command post at the VTRS building. VT Rescue

3, staffed with an ALS crew, stood by at their

station. At about 9:42 a.m., VTRS requested theMontgomery County emergency services coordi-

nator to place all county EMS units on standby

and for him to respond to the VTRS Command

Post. Standby means that all agency units

should be staffed and ready to respond. Each

agency officer in charge is supposed to notify the

appropriate dispatcher when the units are

staffed.

The Montgomery County Communications Cen-

ter immediately paged out an all call alert (9:42

a.m.) advising all units to respond to the scene atNorris Hall.

The EMS responses to West Ambler Johnston

and Norris halls occurred in a timely manner.

However, for the shootings at Norris Hall, all

EMS units were dispatched to respond to the


A


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104

Figure 13. Virginia Tech EMS ICS as Implemented in the Incident

Another issue concerned the staging of units

and personnel. EMS command correctly advised

dispatch that assignments and staging would be

handled by EMS command.10

Triage The VTPD arrived at Norris Hall at

9:45 a.m. At 9:50 a.m., the VTPD and Blacks-

burg police emergency response teams (ERTs)

arrived at Norris Hall, each with a tactical

medic. At 9:50 a.m., two ERT medics entered

Norris Hall where they were held for about 2

minutes inside the stairwell before being al-lowed to proceed. At 9:52 a.m., the two medics,

one from VTRS and one from BVRS, began tri-

age. Medics initially triaged those victims

brought to the stairwells while police were mov-

10

Turner, K.N., & Davis, J. (2007).Public Safety Timelinefor April 16, 2007. Unpublished Report. Montgomery CountyDepartment of Emergency Services, p. 6.

ing them out of the building. As victims exited

the building, some walked and some were car-

ried out and transported by police SUVs and

other mobile units to the safer EMS treatment

areas.

The triage by ERT medics inside the Norris Hall

classrooms had two specific goals: first, to iden-

tify the total number of victims who were alive

or dead; and second, to move ambulatory vic-

tims to a safe area where further triage and

treatment could begin. The tactical medics em-ployed the START triage system (Simple Triage

and Rapid Treatment) to quickly assess a victim

and determine the overall incident status. The

START triage is a method whereby patients in

an MCI are assessed and evaluated on the basis

Virginia Tech RescueSquad EMS

Command


Operations Chief

Montgomery CountyESCPolice

Command PostLiaison

Treatment Officer

Tertiary Triage

Triage Officer

Triage Teams

PrimaryTriage

SecondaryTriage

Staging Officer

Primary Staging(on campus)

SecondaryStaging(Station 1)


Command


Operations Chief

Montgomery CountyESCPolice

Command PostLiaison

Treatment Officer

Tertiary Triage

Triage Officer

Triage Teams

PrimaryTriage

SecondaryTriage

Staging Officer



Treatment Officer

Tertiary Triage

Treatment Officer

Tertiary Triage

Triage Officer

Triage Teams

PrimaryTriage

SecondaryTriage

Triage Officer

Triage Teams

PrimaryTriage

SecondaryTriage

Staging Officer



Staging Officer




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Figure 14. Model ICS Based on the NIMS Guidelines

of the severity of injuries and assigned to treat-

ment priorities.11

Patients are classified in one

of four categories (Figure 15). Colored tags are

affixed to patients corresponding to these catego-ries.

In an incident of this nature, the triage team

must concentrate on the overall situation instead

11WVEMS. (2006). Mass Casualty Incident Plan: EMS

Mutual Aid Response Guide: Western Virginia EMS Council,Section 2.1.8, p. 2.

Immediate

Delayed

Minor

Deceased12

Figure 15. START Triage Patient Classifications

12Critical Illness and Trauma Foundation, Inc. (2001).

STARTSimple Triage and Rapid Treatment.http://www.citmit.org/start/default.htm

EMS Command

VT Rescue

VT Lieutenant

Safety Officer

Norris Hall

Blacksburg Lt.

Liaison Officer

Norris Hall

Montgomery Co.

Coord.

PIO

Police

Operations Chief

VT Rescue

VT Lieutenant

Logistics Chief

VT Rescue

VT Lieutenant

Planning Chief

VT EMS Command

Finance/Admin

VT University Staff

Base

Blacksburg

Rescue

Staging Manager

VT Rescue

Triage GroupNorris Hall

VT Captain

Treatment GroupNorris Hall

VT Lieutenant

TransportationGroup

VT Rescue

Morgue Unit

Norris Hall

Blacksburg Lt.

Initial Triage Unit

Norris Hall

Tactical Medics

Major Treatment

Unit

Norris Hall

Lieutenant

Delayed

Treatment Unit

Barger Street

Minor Treatment

Unit

VT Rescue

Squad

Patient Dispatch

Manager

VT Rescue

Squad

EMT

Medical

Communicator

EMS Command

VT Rescue

VT Lieutenant

Safety Officer

Norris Hall

Blacksburg Lt.

Liaison Officer

Norris Hall

Montgomery Co.

Coord.

PIO

Police

Operations Chief

VT Rescue

VT Lieutenant

Logistics Chief

VT Rescue

VT Lieutenant

Planning Chief

VT EMS Command

Finance/Admin

VT University Staff

Base

Blacksburg

Rescue

Staging Manager

VT Rescue

Triage GroupNorris Hall

VT Captain

Treatment GroupNorris Hall

VT Lieutenant

TransportationGroup

VT Rescue

Morgue Unit

Norris Hall

Blacksburg Lt.

Initial Triage Unit

Norris Hall

Tactical Medics

Major Treatment

Unit

Norris Hall

Lieutenant

Delayed

Treatment Unit

Barger Street

Minor Treatment

Unit

VT Rescue

Squad

Patient Dispatch

Manager

VT Rescue

Squad

EMT

Medical

Communicator


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of focusing on individual patient care. Patient

care is limited to quick interventions that will

make the difference between life and death. The

medics systematically approached the initial tri-

age, with one assessing victims in the odd-numbered rooms on the second floor of Norris

Hall while the other assessed victims in the

even-numbered rooms. The medics were able to

quickly identify those victims who were without

vital signs and would likely not benefit from

medical care. This initial triage by the two tacti-

cal medics accompanying the police was appro-

priate in identifying patient viability. The medics

reported a tough time with radio communica-

tions traffic while triaging in Norris Hall.

The triage medics identified several patients who

required immediate interventions to save their

lives. Some victims with chest wounds were

treated with an Asherman Chest Seal (Figure

16). It functions with a flutter valve to prevent

air from entering the chest cavity during inhala-

tion and permits air to leave the chest cavity

during exhalation. This is a noninvasive tech-

nique that can be applied quickly with low risk.

It was reported that a female victim with chest

wounds benefited by the immediate application

of the seal. Since the scene was not yet secured

at this point to allow other EMS providers toenter, the tactical medics quickly instructed

some police officers how to use the seal.

Figure 16. Asherman Chest Seal13

13ACS (2007). Asherman Chest Seal.

http://www.compassadvisors.biz

A decision was quickly made to treat a 22-year-

old male victim who exhibited a profuse femoral

artery bleed by applying a commercial-brand

tourniquet (Figure 17) to control the bleeding.

The patient was transported to MRH, where sur-gical repair was performed and he survived. The

application of a tourniquet was likely a lifesaving

event.

Figure 17 Tourniquet14

At approximately 10:09 a.m., VTPD dispatch

notified EMS command that the shooter was

down and that EMS crews could enter Norris

Hall. EMS command assigned a lieutenant from

VTRS to become the triage unit leader. Triage

continued inside and in front of Norris Hall.Some critical patients at the Drillfield side and

others at the secondary triage (critical treatment

unit) Old Turner Street side of Norris Hall were

placed in ambulances and transported directly to

hospitals. Noncritical patients were moved to a

treatment area at Stanger and Barger Streets.

A BVRS officer and crew arrived at Norris Hall

and began to retriage victims. Their reassess-

ment confirmed that 31 persons were dead.

Based on the evidence available, the decision not

to attempt resuscitation on those originally tri-aged as dead was appropriate. No one appeared

to have been mistriaged. A medical director

(emergency physician) for a Virginia State Police

Division SWAT team responded with his team to

the scene. He was primarily staged at Burress

Hall and was available to care for wounded

14Medgadget (2007). http://www.medgadget.com


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107

officers if needed. There were no reports of inju-

ries to police officers.

Interviews of prehospital and hospital personnel

revealed that triage ribbons or tags were not

consistently used on victims. The standard triage

tags were used on some patients but not on all.

These triage tags, shown in Figure 18, are part of

the Western Virginia EMS Trauma Triage

Protocol and can assist with record keeping and

patient follow-up.15

Not using the tags may have

led to some confusion regarding patient

identification and classification upon arrival at

hospitals.

Treatment Patients were moved to the treat-ment units based on START guidelines. The

treatment group was divided into three units: acritical treatment unit, a delayed treatment unit

and a minor treatment unit. The critical treat-

ment unit was located at the Old Turner Street

Side of Norris Hall where patients with immedi-

ate medical care needs (red tag) received care.

Patients who were classified as less critical (yel-

low tag) were moved to the delayed treatment

unit at Stanger and Barger Streets. Patients

with minor injuries, including walking wounded/

worried well (green tag) were moved to a minor

treatment unit at VTRS (Figure 19). Worried

well are those who may not present with inju-

ries but with psychological or safety issues.

Patients were moved to the treatment units in

various ways. Some critical patients were carried

out of Norris Hall by police and EMS personnel.

Others were moved via vehicles, while those less

critical walked to the delayed treatment or minor

treatment units. EMS command assigned leaders

to each of the units.

The weather was a significant factor with wind

gusts of up to 60 mph grounding all aeromedicalservices and hampering the use of EMS equip-

ment. This included tents, shelters, and treat-

ment area identification flags that could not be

15WVEMS. (2006). Mass Casualty Incident Plan: EMS

Mutual Aid Response Guide: Western Virginia EMS Council.,Section 22.3, p. 13.

Figure 18. Virginia Triage Tag

set up or maintained. Large vehicles such as

trailers and mobile homes, often used for tempo-

rary shelter, had difficulty responding as high

winds made interstate driving increasingly haz-

ardous. The incident site was close to ongoing

construction. High winds blew debris, increasing

danger to patients and providers and impeding

patient care. To protect the walking wounded/

worried well from the environment, patients


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Figure 19. Initial Location of Treatment Units

were moved to the minor treatment unit at the

VTRS building.

Twelve EMS patient care reports (PCRs) were

available for review. In some cases PCRs were

not completed, and in other cases not provided

upon request. In multiple casualty incident

situations, EMS providers can use standard tri-

age tags in place of the traditional PCR; how-

ever, no triage tag records were provided, as

noted earlier.

Based on the PCRs available and the interviews

of EMS and hospital personnel, it appears thatthe patient care rendered to Norris Hall victims

was appropriate.

Transportation EMS command appointed atransportation group leader who assigned

patients to ambulances and specific hospital

destinations. Christiansburg Rescue Squad

(CRS) responded with BLS and ALS units and

was among the first in line at Norris Hall. CRS,

BVRS, CPTS, and LongshopMcCoy Rescue

Squad transported critical patients to area hos-

pitals. CPTS ambulances from Giles, Radford,

and Blacksburg as well as some of their

Roanoke-based units, including Life-Guard

flight and ground critical care crews, responded

in mass to the incident either at Norris Hall or

by interfacility transport of critical victims. By

10:51 a.m., all patients from Norris Hall were

either transported to a hospital, or moved to the

delayed or minor treatment units. In addition to

VTRS, 14 agencies responded to the incidentwith 27 ALS ambulances and more than 120

EMS personnel (Table 4). Some agencies

delayed routine interfacility patient transports

or back filled covering neighboring communi-

ties through preset mutual aid agreements.

Agency supervisors and administrators were

working effectively behind the scenes procuring

A/B: Staging Areas

C: Command Post

D: Treatment Area(Delayed and MinorTreatment Units)

E: Secondary Triage

(Critical TreatmentUnit)

C

A

DB

E

A/B: Staging Areas

C: Command Post

D: Treatment Area(Delayed and MinorTreatment Units)

E: Secondary Triage

(Critical TreatmentUnit)

C

A

DB

E


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Table 4. EMS Response

14 Assisting Agencies16

Montgomery County Emergency ServicesCoordinator

Blacksburg Volunteer Rescue Squad

Christiansburg Rescue Squad

Shawsville Rescue Squad

Longshop-McCoy Rescue Squad

Carilion Patient Transportation Services

Salem Rescue Squad

Giles Rescue Squad

Newport Rescue Squad

Lifeline Ambulance Service

Roanoke City Fire and Rescue

Vinton First Aid Crew

Radford University EMSCity of Radford EMS

the necessary resources and supporting the

response of their EMS crews. These agencies

demonstrated an exceptional working relation-

ship, likely an outcome of interagency training

and drills.

False Alarm Responses At 10:58 a.m., EMS

command was notified of a reported third shoot-

ing incident at the tennis court area on Wash-

ington Street that proved to be a false alarm. At

11:18 a.m., EMS command was notified of abomb threat at Norris and Holden Halls that

also proved to be false. Due to safety concerns,

EMS command ordered the staging area moved

from Barger St. to Perry St.

Post-Incident Transport of the Deceased

At 4:03 p.m., the medical examiner authorized

removal of the deceased from Norris Hall to the

medical examiners office in Roanoke. Due to

another rescue incident in the Blacksburg area,

units were not available until 5:15 p.m. to begin

transport of the deceased. Several options wereconsidered including use of a refrigeration

truck, funeral coaches, or EMS units. EMS

command, in consultation with the medical

examiners representative, determined that

16VTRS. (2007).April 16, 2007: EMS Response. Presenta-

tion to the Virginia Tech Review Panel. May 21, 2007, TheInn at Virginia Tech.

EMS units from several companies would trans-

port the deceased to Roanoke. In general, front-

line EMS units are not used to transport the

deceased. In this instance, however, the use of

EMS units was acceptable because emergencycoverage was not neglected and the rescuers felt

that the sight of a refrigeration truck and

funeral coaches on campus would be undesir-

able.

The decedents were placed two to a unit for

transport. A serious concern raised by EMS pro-

viders was an order given by an unidentified

police official that the decedents be transported

to Roanoke under emergency conditions (lights

and sirens). Due to safety considerations, EMS

command modified this order.

The police order to transport the deceased under

emergency conditions from Norris Hall to the

medical examiners office in Roanoke was in-

appropriate for several reasons:

It is not within law enforcements scope

of practice to order emergency transport

(red lights and siren) of the deceased.

There was no benefit to anyone by

transporting under emergency condi-

tions.

A 30-minute or longer drive to Roanoke,

during bad weather, with winds gusting

above 60 mph, exposes EMS personnel

to unnecessary risks.

Transporting under emergency condi-

tions increases the possibility of vehicle

crashes with risk to civilians.

Critical Incident Stress Management

Although no physical injuries were reported,

psychological and stress- related issues can sub-

sequently manifest in EMS providers. Local andregional EMS providers participated in critical

incident stress management activities such as

defusings and debriefings immediately post-

incident.


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HOSPITAL RESPONSE

atients from Virginia Tech were treated at

five area hospitals:

Montgomery Regional Hospital

Carilion New River Valley Hospital

LewisGale Medical Center

Carilion Roanoke Memorial Hospital

Carilion Roanoke Community Hospital

Twenty-seven patients are known to have been

treated by local emergency departments. Some

others who were in Norris Hall may have been

treated at other hospitals, medical clinics, or

doctors offices including their own primary care

providers; but there are no known accounts.

Overall, the local and regional hospitals quickly

implemented their hospital ICS and mobilized

resources. Aggressive measures were taken to

postpone noncritical procedures, shift essential

personnel to critical areas, reinforce physician

staffing, and prepare for patient surge. Three

hospitals initiated their hospital-wide emer-

gency plans. One hospital, a designated Level I

trauma center, did not feel that a full-scale,

hospital-wide implementation of their emer-

gency plan was necessary.

The most significant challenge early on was the

lack of credible information about the number of

patients each expected to receive. The emer-

gency departments did not have a single official

information source about patient flow. Likely

explanations for this were (1) an emergency

operations center (EOC) was not opened at the

university, and (2) the Regional Hospital Coor-

dinating Center did not receive complete infor-

mation that it should have under the MCI

plan.

17

Preparedness, patient care/patient flow, and

patient outcomes were reviewed for each of the

receiving hospitals.

17Personal communications, Morris Reece, Near Southwest

Preparedness Alliance, June 15, 2007.

Montgomery Regional Hospital The MRHemergency department, a Level III trauma cen-

ter, received 17 patients from the Virginia Tech

incident; two from West Ambler Johnston and

15 from Norris Hall. The patients from WAJarrived at 7:51 and 7:55 a.m. The first patient

from WAJ was the 22-year-old male with a gun-

shot wound to the head who was DOA. No fur-

ther attempts at resuscitation were made in the

emergency department.

The second patient from WAJ was the 18-year-

old female who arrived in critical condition with

a gunshot wound to the head. Upon arrival to

the emergency department, she was unable to

speak and her level of consciousness was dete-

riorating. Airway control via endotracheal intu-

bation was achieved using rapid sequence in-

duction. At 8:30 a.m., she was transported by

ALS ambulance to Carilion Roanoke Memorial

Hospital, the Level I trauma center for the

region. She died shortly after arrival at CRMH.

HOSPITALPREPAREDNESS: At 9:45 a.m., MRH was

notified of shots fired somewhere on the

Virginia Tech campus. Because they were un-

sure of the number of shooters or whether the

incident was confined to campus, MRH initiated

a lockdown procedure. Since the killing of a hos-

pital guard at MRH in August 2006 (the Morva

incident mentioned in Chapter VII), there has

been heightened awareness at MRH regarding

security procedures. At 10:00 a.m., information

became available confirming multiple gunshot

victims. A code green (disaster code) was initi-

ated and the following actions were taken:

The hospital incident command center

was opened and preassigned personnel

reported to command.

The hospital facility was placed on acontrolled access plan (strict lockdown).

Only personnel with appropriate identi-

fication (other than patients) could enter

the hospital and then only through one

entrance.

All elective surgical procedures were

postponed.

P


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111

Day surgery patients with early surgery

times were sent home as soon as possi-

ble.

The emergency department was placed

on divert for all EMS units except thosearriving from the Norris Hall incident.

The emergency department was staffed

at full capacity. A rapid emergency

department discharge plan was insti-

tuted. Stable patients were transferred

from the emergency department to the

outpatient surgery suite.

At 10:05 a.m., the first patient from Norris Hall

arrived via self-transport. This patient was

injured escaping from Norris Hall. MRH was

unable to determine the extent of the NorrisHall incident based on the history and minor

injuries of this patient. The Regional Hospital

Coordinating Center (RHCC) was notified of the

incident and asked to open. Although the RHCC

had early notification of the incident, they too

were not able to ascertain the extent of the cri-

sis initially.

At 10:14 and 10:15 a.m., two EMS-transported

patients from Norris Hall arrived. It was evi-

dent that MRH might continue to receive

expected and unexpected patients. In prepara-tion for the surge, MRH took the following addi-

tional actions:

The Red Cross was alerted and the blood

supply reevaluated.

Additional pharmaceutical supplies and

a pharmacist were sent to the emer-

gency department.

A runner was assigned to assist with

bringing additional materials to and

from the emergency department and the

pharmacy.

Disaster supply carts were moved to the

hallways between the emergency

department and outpatient surgery.18

18Montgomery Regional Hospital. (2007). Montgomery

Regional Hospital VT Incident Debriefing. April 23, 2007,p. 1.

At 10:30 a.m. as the above actions were being

taken, four more gunshot victims arrived via

EMS transport from Norris Hall. Between 10:45

and 10:55 a.m., five additional patients arrived

via EMS. Command designated a public infor-mation officer and, by 11:00 a.m., a base had

been established where staff and counselors

could assist family and friends of patients.

By 11:15 a.m., MRH was still unclear about how

many additional patients to expect. (They had a

total of 12 by this time.) The operations chief

instructed an emergency administrator to

respond to the Virginia Tech incident as an on-

scene liaison to determine how many more

patients would be transported to MRH. At 11:20

a.m., the emergency department administrator

reported to the Virginia Tech command center.

MRH said that the face-to-face communications

were helpful in determining how many addi-

tional patients to expect.

At 11:40 a.m., MRH received its last gunshot

victim from the incident. By 11:51 a.m., its on-

scene liaison confirmed that all patients had

been transported. At 12:12 p.m., the EMS divert

was lifted. At 13:04 and 13:10 p.m., however,

two additional patients from the incident

arrived by private vehicle. At 13:35 p.m., the

code green was lifted.

PATIENTCARE/PATIENTFLOW/PATIENTOUTCOMES: In

all, 15 patients arrived at MRH from the Norris

Hall incident (Table 5) and were managed well.

An emergency department (ED) nurse/EMT-C

was assigned to online medical direction and

assisted with directing patients to other hospi-

tals. EMS was instructed to transport four

patients to Carilion New River Valley Hospital

and five patients to LewisGale Medical Center.

One patient from the Norris Hall incident wastransferred from MRH to CRMH in Roanoke.

The hospital representatives reported that there

were problems with patient identification and

tracking. As noted earlier:


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Table 5. Norris Hall Victims Treated by

Montgomery Regional Hospital

Injuries Disposition

GSW left hand fractured

4th finger

OR and admission

GSW to right chest hemothorax

Chest tube in OR andadmission

GSW to right flank OR and admission toICU

GSW left elbow, right thigh Admitted

GSW x 2 to left leg OR and admission

GSW right bicep Treated and discharged

GSW right arm, grazed chestwall; abrasion to left hand

Admitted

GSW right lower extremity;

laceration to femoral artery

OR and ICU

GSW right side abdomenand buttock

OR and ICU

GSW right bicep Treated and discharged

GSW to face/head Intubated and trans-ferred to CRMH

Asthma attack precipitatedby running from building

Treated and discharged

Tib/fib fracture due to jump-ing from a 2

nd-story window

OR and admission

First-degree burns to chestwall


Back pain due to jumping

from a 2nd-story window


An EOC was not activated at Virginia

Tech. Establishing an EOC can enhance

communications and information flow to

hospitals.

Triage tags were not used for all

patients. This would have provided a

discrete number for identifying and

tracking each patient.

MRH activated its ICS as shown in Figure 20.

ACCOMMODATIONS FORPATIENTSFAMILIES AND

FRIENDS:MRH accommodated families and

friends of patients they treated in their emer-

gency department. MRH was challenged by the

need to provide assistance to those who were

unsure of the status or location of persons they

were trying to find (possibly victims). An open

space on the first floor was used for family and

friends to gather. Since Virginia Tech had not

yet opened an EOC or family assistance center,

some victims family and friends chose to pro-

ceed to the closest hospital. Several family

members and friends of victims came to MRHeven though their loved ones were never trans-

ported there.

A psychological crisis counseling team was

assembled at MRH to provide services to vic-

tims, their families and loved ones, and hospital

staff.19

Virginia State Police troopers were

assigned to the hospital and were helpful in

maintaining security.

At 11:30 a.m., a surgeon arrived from Lewis

Gale Hospital and was emergently credentialed

by the medical staff office. This is notable asLewisGale and MRH are not affiliated.

Police departments often rely on hospitals to

help preserve evidence and maintain a chain of

custody. MRH was able to gather evidence in

the emergency department and operating

rooms, including bullets, clothing, and patient

identification. At 1:45 p.m., the Virginia State

Police notified the hospital that all bullets and

fragments were to be considered evidence.

Internal communications issues included:

The Nextel system was overwhelmed.

Clinical directors were too busy to

retrieve and respond to messages.

Monitoring EMS radio communications

was difficult due to noise and chatter.

There was deficient communications

between the university and MRH.

An EOC could have been helpful with

communications.

19Heil, J. et al. (2007).Psychological Intervention with the

Virginia Tech Mass Casualty: Lessons Learned in the Hospi-tal Setting. Report to the Virginia Tech Review Panel.


13/22


14/22


114

Carilion New River Valley Hospital

CNRVH is a Level III trauma center that

received four patients with moderate to severe

injuries.

HOSPITALPREPAREDNESS:CNRVH initially heard

unofficial reports of the WAJ shootings. They

heard nothing further for over 2 hours until

they received a call from MRH and also from an

RN/medic who was on scene. They were called

again later by MRH and advised that they

would be receiving patients with extremity

injuries. They were also notified that MRH was

on EMS divert.

While waiting for patients to arrive, the emer-

gency department (ED) physician medical direc-

tor assumed responsibility for the regular EDpatients while the on-duty physicians were pre-

paring to treat patients from Norris Hall. The

on-duty hospitalist (a physician who is hired by

the hospital to manage in-patient care needs)

reported to the ED to make rapid decisions on

whether current patients would be admitted or

discharged.

The hospital declared a code green and their

EOC was opened at 11:50 a.m. The incident

commander was a social worker who had special

training in hospital ICS. Security surveyed allpatients with a metal detection wand because

they were unsure who may be victims or perpe-

trators. A SWAT team from Pulaski County

responded to assist with security.

PATIENTCARE/PATIENTFLOW/PATIENTOUTCOMES:

Four patients were transported by EMS to

CNRVH, each having significant injuries. The

hospital managed the patients well and could

have handled more. Table 6 lists the patient

injuries and dispositions.

ACCOMMODATIONS FORPATIENTSFAMILIES AND

FRIENDS:The hospital received many phone calls

concerning the whereabouts of Virginia Tech

shooting victims. Communications issues, par-

ticularly the lack of accurate information, were

a big concern for the hospital; while providing

accommodations for patients families and

friends and assisting others who were looking

for their loved ones.

Table 6. Norris Hall Victims Treated by Carilion New

River Valley Hospital


GSW to face, pre-auriculararea, bleeding from externalauditory canal, GCS of 7, poorairway, anesthesiologist rec-ommended surgical airway

Surgical cricothyro-tomy

Transferred to CRMHby critical care ALSambulance

GSW to flank and right arm,hypotensive

Immediately taken toOR; small bowelinjury/resection

GSW to posterior thorax (exitright medial upper arm), addi-tional GSWs to right buttock,

and left lateral thigh

To OR for surgicalrepair of left femurfracture

GSW to right lateral thigh, exitthru right medial thigh, lodgedin left medial thigh

Admitted in stablecondition andobserved; no vascularinjuries

LewisGale Medical Center LGMC, a com-

munity hospital, received five patients from the

Norris Hall shootings. The ICS structure used

and their emergency response to the incident

were appropriate. Multiple casualty incidents

and use of the ICS were not new to LGMC.

Their ICS had been recently tested after an out-

break of food poisoning at a local college.

HOSPITALPREPAREDNESS:LGMC first became

aware of the Norris Hall incident when a call

was received requesting a medical examiner.

They were unable to fulfill the request. At 11:10

a.m., they received a call from Montgomery

Regional Hospital advising them of the incident.

LGMC immediately declared a code aster,

which is their disaster plan.

The code aster was announced throughout the

hospital, the EOC was opened, and the ICS was

initiated. At 11:16 a.m., they were notified that

MRH was on EMS diversion. At 11:32 a.m., they

were notified that they were receiving their first

patient suffering from a gunshot wound. In

addition to preparing for the patients to arrive

at their own hospital, LGMC sent a surgeon to

MRH to assist with the surge of surgical

patients there.


15/22


115


EMS transported five patients from the Norris

Hall shootings to LGMC. Table 7 lists the

patient injuries and dispositions. These patients

were well managed.

Table 7. Norris Hall Victims Treated by

LewisGale Medical Center


GSW grazed shoulder andlodged in occipital area, didnot enter the brain

Patient taken to sur-gery by ENT fordebridement

GSW in back of right arm,bullet not removed

Patient admitted forobservation

GSW to face, bullet fragmentin hair, likely secondary toshrapnel spray

Treated in ED andreleased

Jumped from Norris Hall, 2ndfloor, shattered tib/fib

Admitted, taken to sur-gery the next day

Jumped from Norris Hall, 2ndfloor, soft tissue injuries,neck and back sprain, re-portedly was holding handswith another jumper

Treated in ED andreleased

ACCOMMODATION FORPATIENTSFAMILY AND FRIENDS:

No specific information was obtained from

LGMC about accommodations for patients fami-

lies and friends. However, the hospitals needs

for accurate information while accommodating

patient families and friends and assisting

others in attempting to locate loved ones are

similar for all emergency departments in times

of mass casualty incidents.

Carilion Roanoke Memorial Hospital This

Level I trauma facility located in Roanoke

received three critical patients transferred from

local hospitals. Two patients were transported

from MRH (one from the WAJ incident and one

from the Norris Hall incident). The third patient

was transferred from CNRVH (from the Norris

Hall incident).

HOSPITALPREPAREDNESS:CRMH did not initiate

its hospital-wide disaster plan since standard

procedures allowed for effective incident man-

agement with the relatively small number of

patients received. They did initiate a gold

trauma alert that brings to the ED three

nurses, one trauma attending physician, one

trauma fellow physician, one radiologist, one

anesthesiologist, and a lab technician.

In addition to the patient transfers, CRMH

received a trauma patient from another inci-

dent. The ED had three other emergency physi-

cians physically present with others on standby.

A neurosurgeon was also in the ED awaiting the

arrival of transfer patients.

CRMHs concerns echoed those of the other hos-

pitals who received patients from the Virginia

Tech incident, including lack of clarity as to

expected patient surge and the need for better

regional coordination. It was suggested that the

RHCC Mobile Communications Unit could have

been dispatched to the scene.


CRMH appropriately triaged and managed well

the patients they received. Adequate staffing

and operating rooms were immediately avail-

able. Table 8 lists WAJ and Norris Hall victims

treated at CRMH.

Table 8. WAJ and Norris Hall Victims Treated by

Carilion Roanoke Memorial Hospital


Transfer from MRH, se-

vere head injury

Pronounced dead in ED

Transfer from MRH, headand significant facial/jawinjuries, subsequent oro-tracheal intubation

Patient taken to OR forsurgery, subsequentlytransferred to a facilitycloser to home

Transfer from CNRVH,GSW to face, subsequentcricothyrotomy

Patient taken to OR forsurgery

Carilion Roanoke Community Hospital

CRCH is a community hospital located near and

associated with CRMH. CRCH treated a self-

transported student who was injured by jump-

ing from Norris Hall. Table 9 lists the injuriesand disposition of this patient.

Table 9. Norris Hall Victim Treated by Carilion

Roanoke Community Hospital


Ankle contusion and sprainsecondary to jumping

Treated and released


16/22


116

EMERGENCY MANAGEMENT

ulticasualty incidents often require coor-

dination among state, regional, and local

authorities. This section reviews the inter-

relationships of these authorities.

Virginia Department of Health In 2002,

the Virginia Department of Health (VDH) was

awarded funding from the Health Resources and

Services Administration (HRSA) National

Bioterrorism Hospital Preparedness Program

(NBHPP) for enhancement of the health and

medical response to bioterrorism and other

emergency events. As part of this process, VDH

developed a contract with the Virginia Hospital

and Healthcare Association (VHHA) to manage

the distribution of funds from the HRSA grant

to state acute care hospitals and other medical

facilities and to monitor compliance. A small

percentage of the HRSA funds were used within

VDH to fund a hospital coordinator position, as

well as to partially fund a deputy commissioner

and other administrative positions. Substan-

tially more than 85 percent of this HRSA grant

funding was distributed to hospitals or used for

program enhancement, including development

of a web-based hospital status monitoring sys-

tem, multidisciplinary training activities,

behavioral health services, and poison control

centers.

At the same time, VDH received separate fund-

ing from the Centers for Disease Control and

Prevention (CDC) for the enhancement of public

health response to bioterrorism and other emer-

gency events. The position of VDH Deputy

Commissioner for Emergency Preparedness and

Response was created, with responsibility for

both CDC and HRSA emergency preparedness

funds. The physician in this position reports

directly to the state health commissioner, who

serves as the state health officer for Virginia.20

20Kaplowitz, L, Gilbert, C. M., Hershey, J. H., and Reece,

M. D. (2007). Health and Medical Response to ShootingEpisode at Virginia Tech, April, 2007: A Successful

Approach. Unpublished Manuscript. Virginia Department ofHealth, p. 2.

The Virginia Department of Health regional

planning approach aligns hospitals with health

department planning regions. In collaboration

with the 88 acute care hospitals in the Com-

monwealth, six hospital and healthcare plan-ning regions were established, closely corre-

sponding with five health department planning

regions. Each of the six hospital planning

regions has a designated Regional Hospital

Coordinating Center (RHCC) located at or near

the Level I trauma facility in the region as well

as a regional hospital coordinator funded

through the HRSA cooperative agreement.

Near Southwest Preparedness Alliance

The Near Southwest Preparedness Alliance

(NSPA), which covers the Virginia Tech area,

was developed under the auspices of the West-

ern Virginia EMS Council pursuant to a memo-

randum of understanding between the Virginia

Department of Health, the Virginia Hospital

and Healthcare Association, and the NSPA.

NSPA is organized to facilitate the development

of a regional healthcare emergency response

system and to support the development of a

statewide healthcare emergency response sys-

tem. Regional hospital preparedness and coor-

dination will foster collaborative planning

efforts between the several medical care facili-ties and local emergency response agencies in

the established geographically and demographi-

cally diverse region.21

The Near Southwest region is defined as:

4th Planning District (New River area),

which includes Floyd, Giles, Montgom-

ery, and Pulaski counties and the City of

Radford.

5th Planning District (Roanoke and

Alleghany area), which includesAlleghany, Botetourt, Craig, and Roa-

noke counties as well as the cities of

Covington, Roanoke, and Salem.

11th Planning District,whichincludesAmherst, Appomattox, Bedford, and

21Ibid.

M


17/22


117

Campbell counties; the cities of

Lynchburg and Bedford; and the towns

of Altavista, Amherst, Appomattox, and

Brookneal.

12th Planning District (Piedmont area),which includes Franklin, Henry, Patrick

and Pittsylvania counties and the cities

of Danville and Martinsville

The region covers 7,798 square miles and

houses a population of 910,900. It has 24 local

governments and 16 hospitals.

Regional Hospital Coordinating CenterAt the regional level, hospital emergency

response coordination during exercises and

actual events is provided by RHCCs that have

been established to facilitate emergency

response, communication, and resource alloca-

tion within and among each of the six hospital

regions. These centers serve as the contact

among healthcare facilities within the region

and with RHCCs in other state regions. RHCCs

are also linked to the statewide response system

through the hospital representative seat at the

VDH Emergency Coordinating Center (ECC) in

Richmond, Virginia. The hospital seat at the

ECC serves as the contact between the health-

care provider system and the statewide emer-gency response system. It provides a communi-

cation link to the Virginia Emergency Opera-

tions Center (VEOC).22

The primary responsibilities of the RHCC

include:

Provide a single point of contact between

hospitals in the region and the VDH

ECC.

Collect and disseminate initial event no-

tification to hospitals and public safety

partners.

Collect and disseminate ongoing situ-

ational awareness updates and warn-

ings, including the management of the

current bed availability in hospitals.

22Ibid.

Establish and manage WebEOC23

and

communications systems for the dura-

tion of the incident.

Serve as the single point of contact and

collaboration point for Virginia fire/EMSagencies for the purposes of hospital di-

version management, movement of

patients from an incident scene to

receiving hospitals, and input/guidance

with respect to hospital capabilities,

available services, and medical trans-

port decisions.

Coordinate interhospital patient move-

ment, transfers, and tracking

Provide primary resource management

to hospitals for:Personnel

Equipment

Supplies

Pharmaceuticals.

Coordinate regional expenditures for

reimbursement.

Coordinate regional medical treatment

and infection control protocols during

the incident as needed.

Coordinate Virginia hospital requests

for the Strategic National Stockpilethrough the local jurisdiction EOC.

The RHCC complements but does not replace

the relationships and coordinating channels

established between individual healthcare

facilities and their local emergency operations

centers and health department officials. The

regional structure is intended to enhance the

communication and coordination of specific

issues related to the healthcare component of

the emergency response system at both regional

and state levels.

At 10:05 a.m. on April 16, MRH requested that

the RHCC be activated. At 10:19 a.m., it was

activated under a standby status and signed on

23WebEOC is a web-based information management system

that provides a single access point for the collection anddissemination of emergency or event-related information


18/22


118

to WebEOC.24

By 10:25 a.m., the Virginia De-

partment of Health also had signed on to

WebEOC and monitored the event. At 10:40

a.m., the RHCC requested that all hospitals

provide an update of bed status and diversionstatus for their facility. By 10:49 a.m., LGMC

was the only hospital that signed on to WebEOC

of the hospitals that had received patients from

the Norris Hall incident. Pulaski County Hospi-

tal also signed on and provided their status. At

11:49 a.m. (1 hour later), MRH signed on fol-

lowed by CNRVH at 12:33 p.m.25

The WebEOC boards (the RHCC Events Board

and the Near Southwest Region Events Board)

were used for a variety of communications

between the RHCC, hospitals, and other state

agencies. Some hospitals spent considerable

time attempting to post information on the

WebEOC boards. None of the EMS jurisdictions

signed on to either of the boards. Not all hospi-

tals or EMS agencies are confident in using

WebEOC and require regular training drills for

familiarity.

The hospitals and public safety agencies should

have used the RHCC and WebEOC expedi-

tiously to gain better control of the situation.

Considering the many rumors and unconfirmed

reports concerning patient surge, the incident

could have been better coordinated. If the RHCC

was kept informed as per the MCI plan, it could

have acted as the one official voice for informa-

tion concerning patient status and hospital

availability.

Western Virginia EMS Mass Casualty Inci-

dent Plan The Western Virginia EMS region

encompasses the 7 cities and 12 counties of

Virginia Planning Districts 4, 5, and 12. The

region extends from the West Virginia border to

the north and to the North Carolina border to

the south. The region encompasses the urban

and suburban areas of Roanoke and Danville, as

well as many rural and remote areas such as

24Baker, B. (2007). VA Tech 4-16-2007: RHCC Events

Board, p. 1.25

Baker, B. (2007).April 16, 2007: Near Southwest RegionEvents Board, p. 1.

those in Patrick, Floyd, and Giles counties. The

regions total population (based on 1998 esti-

mates) is 661,200. The region encompasses

9,643 square miles.

The region encompasses the counties of

Alleghany, Botetourt, Craig, Floyd, Franklin,

Giles, Henry, Montgomery, Patrick, Pittsylva-

nia, Pulaski, and Roanoke (Figure 21).26

Figure 21. Map Showing Counties in the

Western Virginia EMS Region27

Multicasualty Incidents The Western

Virginia EMS Mass Casualty Incident Plan

(WVEMS MCI) plan defines a multiple casualty

incident as an event resulting from man-made

or natural causes which results in illness and/orinjuries that exceed the emergency medical ser-

vices capabilities of a hospital, locality, jurisdic-

tion and/or region.28

Online medical direction is

the responsibility of the MCI Medical Control,

defined as:

That medical facility, designated by the

hospital community, which provides remote

overall medical direction of the MCI or

evacuation scene according to predeter-

mined guidelines for the distribution of

patients throughout the community.29

26WVEMS. (2006). Trauma Triage Plan. Western Virginia

EMS Council, Appendix E.27

Ibid.28

WVEMS. (2006). Mass Casualty Incident Plan: EMSMutual Aid Response Guide: Western Virginia EMS Council,Section 2.1.1, p. 1.29

Ibid., Section 2.1.4, p. 1.


19/22


119

Access to online physician medical direction

should be available. In MCI situations, modern

EMS systems rely more on standing orders and

protocols and less on online medical direction.

Therefore, it may be more logical to have theRHCC coordinate these efforts, including patch-

ing in providers to online physician medical

direction as needed.

The MCI plan identifies three levels of incidents

based on the initial EMS assessment using the

Virginia START Triage System:

Level 1 Multiple-casualty situation

resulting in less than 10 surviving vic-

tims.

Level 2 Multiple casualty situation

resulting in 10 to 25 surviving victims.

Level 3 Mass casualty situation result-

ing in more than 25 surviving victims.30

The Virginia Tech incident clearly fits into the

definition of a Level 3 MCI, since at least 27

patients were treated in local emergency

departments.

Frustrating communications issues and barriers

occurred during the incident. Every service

operated on different radio frequencies making

dispatch, interagency, and medical communica-

tions difficult. These issues included both on-

scene and in-hospital situations that could be

avoided. Specific communications challenges

included the following:

The radios used by responding agencies

consisted of VHF, UHF, and HEAR fre-

quencies. This led to on-scene communi-

cations difficulties and the inability for

EMS command or Virginia Tech dis-

patch to assure that all units were

aware of important information.

Communications between the scene and

the hospitals were too infrequent. Hos-

pitals were unable to understand exactly

what was going on at the scene. They

30Ibid., Section 7, p. 4.

were unable to determine the appropri-

ate level of preparation.

In several instances, on-scene providers

called hospitals or other resources

directly instead of through the ICS. Thisincluded relaying incorrect information

to hospitals.

Cell phones and blackberries worked

intermittently and could not be relied

upon. Officials did not have time to

return or retrieve messages left on cell

phones. A mobile cell phone emergency

operating system was not immediately

available to EMS providers.

Interviews with EMS and hospital personnel

reiterated a well-known fact: face-to-face com-munications, when practical, is the preferred

method.

From a technological standpoint, the NIMS

requirement for interoperability is critical. Local

communities must settle historical issues and

move forward toward an efficient communica-

tions system.

Lack of a common communications system

between on-scene agencies creates confusion

and could have caused major safety issues forresponders. Each jurisdiction having its own

frequencies, radio types, dispatch centers, and

procedures is a sobering example of the lack of

economies of scale for emergency services. Local

political entities must get past their inability to

reach consensus and assure interoperability of

their communications systems. In this case, the

most reasonable and prudent action probably

would be to expand the Montgomery County

Communications System to handle all public

safety communications within the county. Coop-

eration, consensus building, and the provision ofadequate finances are required by emergency

service leaders and governmental entities. Fail-

ure to accomplish this goal will leave the region

vulnerable to a similar situation in the future

with potentially tragic results.

Unified Command There is little evidence

that there was a unified command structure at


20/22


120

the Virginia Tech incident. Command posts

were established for EMS and law enforcement

at the Norris Hall scene and for law enforce-

ment at another location. Separate command

structures are traditional for public safety agen-cies. The 9/11 attack in New York City exempli-

fied the need for public safety agencies to step

back and reconsider these traditions. At Norris

Hall, a unified command structure could have

led to less confusion, better use of resources,

better direction of personnel, and a safer work-

ing environment. Figure 22 depicts a proposed

model unified command structure that could

have been utilized.

The unified command post would be staffed by

those having statutory authority. During the

Virginia Tech incident, those personnel would

likely have been the police chiefs for VTPD and

the BPD, a university official, a VT EMS officer,

a BVRS EMS officer, the FBI special agent-in-

charge, the state police superintendent, and the

ranking elected official for the City of Blacks-

burg. The operations section chief would havereceived operational guidelines from the unified

command post and assured their implementa-

tion.

The unified command team would be in direct

communications with the EOC and policymak-

ing group. Command and general staff members

would have communicated with their counter-

parts in the EOC. The policymaking group

would have transmitted their requests to the

EOC and the unified command post.

*For this incident, law enforcement would have been the lead agency. The unified command post would be staffed by

those having statutory authority. During the Virginia Tech Incident, those personnel would likely have been the police

chiefs for the VTPD and BPD, a university official, a VT EMS officer, the FBI special agent-in-charge, the Virginia State

Police superintendent, and the ranking elected official for the City of Blacksburg.

Figure 22. Proposed Model Unified Command Structure for an April 16-Like Incident

Unified

Command*

Safety Officer

EMS or Fire

Liaison Officer

Montgomery County

Emergency Coord.

PIOJoint Information

Center

Planning

Section Chief

VT Police or VTRS

Finance/

Administration

Virginia Tech Univ.

Logistics

Section Chief

Virginia Tech EMS

Operations

Section Chief

Virginia Tech or

Blacksburg Police

Law

Enforcement

Branch

EMS

Branch

Deputy Planning

Section Chief

FBI or ATF Assistant

Special Agent In

Charge (ASAIC)

Unified

Command*

Safety Officer

EMS or Fire

Liaison Officer

Montgomery County

Emergency Coord.

PIOJoint Information

Center

Planning

Section Chief

VT Police or VTRS

Finance/

Administration

Virginia Tech Univ.

Logistics

Section Chief

Virginia Tech EMS

Operations

Section Chief

Virginia Tech or

Blacksburg Police

Law

Enforcement

Branch

EMS

Branch

Deputy Planning

Section Chief

FBI or ATF Assistant

Special Agent In

Charge (ASAIC)


21/22


121

Emergency Operations Center The lack ofan EOC activated quickly as the incident un-

folded led to much of the confusion experienced

by hospitals and other resources within the

community. An EOC should have been activatedat Virginia Tech. The EOC is usually located at

a pre-designated site that can be quickly acti-

vated. Its main goals are to support emergency

responders and ensure the continuation of

operations within the community. The EOC

does not become the incident commander but

instead concentrates on assuring that necessary

resources are available.

A policy-making group would function within

the EOC. Virginia Tech had assembled a policy

making group that functioned during the inci-

dent.

Another responsibility of the EOC is the estab-

lishment of a joint information center (JIC) that

acts as the official voice for the situation at

hand. The JIC would coordinate the release of

all public information and the flow of informa-

tion concerning the deceased, the survivors,

locations of the sick and injured, and informa-

tion for families of those displaced. By not im-

mediately activating an EOC, hospitals or the

RHCC did not receive appropriate or timely

information and intelligence. There was also a

delay in coordinating services for families and

friends of victims who needed to be identified or

located. Although Virginia Tech eventually set

up a family assistance center, it was not done

immediately.

KEY FINDINGS

Positive Lessons

The EMS responses to the West Ambler Johns-

ton residence hall and Norris Hall occurred in atimely manner.

Initial triage by the two tactical medics accom-

panying the police was appropriate in identify-

ing patient viability.

The application of a tourniquet to control a

severe femoral artery bleed was likely a life-

saving event.

Patients were correctly triaged and transported

to appropriate medical facilities.

The incident was managed in a safe manner,

with no rescuer injuries reported.

Local hospitals were ready for the patient surge

and employed their NIMS ICS plans and man-

aged patients well.

All of the patients who were alive after the

Norris Hall shooting survived through discharge

from the hospitals.

Quick assessment by a hospitalist of emergencydepartment patients waiting for disposition

helped with preparedness and patient flow at

one hospital.

The overall EMS response was excellent, and

the lives of many were saved.

EMS agencies demonstrated an exceptional

working relationship, likely an outcome of

interagency training and drills.

Areas for Improvement

All EMS units were initially dispatched by the

Montgomery County Communications Center to

respond to the scene; this was contrary to the

request.

There was a 4-minute delay between VTRS

monitoring the incident (9:42 a.m.) on the police

radio and its being dispatched by police (9:46

a.m.).

Virginia Tech police and the Montgomery

County Communications Center issued separate

dispatches. This can lead to confusion in anEMS response.

BVRS was initially unaware that VTRS had

already set up an EMS command post. This

could have caused a duplication of efforts and

further organizational challenges. Participants

interviewed noted that once a BVRS officer

reported to the EMS command post, communi-


22/22


cations between EMS providers on the scene

improved.

Because BVRS and VTRS are on separate pri-

mary radio frequencies, BVRS reportedly did

not know where to stage their units. In addition,

BVRS units were reportedly unaware of when

the police cleared the building for entry.

Standard triage tags were used on some

patients but not on all. The tags are part of the

Western Virginia EMS Trauma Triage Protocol.

Their use could have assisted the hospitals with

patient tracking and record management. Some

patients were identified by room number in the

emergency department and their records

became difficult to track.

The police order to transport the deceased under

emergency conditions from Norris Hall to the

medical examiners office in Roanoke was

inappropriate.

The lack of a local EOC and fully functioning

RHCC may lead to communications and opera-

tional issues such as hospital liaisons being sent

to the scene. If each hospital sent a liaison to

the scene, the command post would have been

overcrowded.

A unified command post should have been

established and operated based on the NIMS

ICS model.

Failure to open an EOC immediately led to

communications and coordination issues during

the incident.

Communications issues and barriers appeared

to be frustrating during the incident.

RECOMMENDATIONS

IX-1 Montgomery County, VA should

develop a countywide emergency medical

services, fire, and law enforcement commu-

nications center to address the issues of

interoperability and economies of scale.

IX-2 A unified command post should be

established and operated based on the

National Incident Management System

Incident Command System model. For this

incident, law enforcement would have been the

lead agency.

IX-3 Emergency personnel should use the

National Incident Management System

procedures for nomenclature, resource typ-

ing and utilization, communications,

interoperability, and unified command.

IX-4 An emergency operations center must

be activated early during a mass casualty

incident.

IX-5 Regional disaster drills should be

held on an annual basis.The drills shouldinclude hospitals, the Regional Hospital Coordi-nating Center, all appropriate public safety and

state agencies, and the medical examiners

office. They should be followed by a formal post-

incident evaluation.

IX-6 To improve multi-casualty incident

management, the Western Virginia Emer-

gency Medical Services Council should

review/revise the Multi-Casualty Incident

Medical Control and the Regional Hospital

Coordinating Center functions.

IX-7 Triage tags, patient care reports, or

standardized Incident Command System

forms must be completed accurately and

retained after a multi-casualty incident.

They are instrumental in evaluating each com-

ponent of a multi-casualty incident.

IX-8 Hospitalists, when available, should

assist with emergency department patient

dispositions in preparing for a multi-

casualty incident patient surge.

IX-9 Under no circumstances should thedeceased be transported under emergency

conditions. It benefits no one and increases the

likelihood of hurting others.

IX-10 Critical incident stress management

and psychological services should continue

to be available to EMS providers as needed.

virginia tech shootings review panel report - 16 chapter ix

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